Evidence-based pediatric pain management (EBPPM) has been identified as a practice too often overlooked in Emergency Departments (EDs). Studies show EBPPM is practiced inconsistently in urban EDs, and even less is known about the practice in rural EDs. The objectives of this study were: A) Determine the frequencies with which specific EBPPM practices are used in EDs of a primarily rural state; and B) Explore the differences in EBPPM practice in Critical Access, rural, and urban hospital EDs. A web-based survey, measuring the use of 14 EBPPM practices, was offered to all licensed independent providers (Medical Doctors, Doctors of Osteopathy, Physicians' Assistants, and Advanced Registered Nurse Practitioners) and nurses from the 118 hospital EDs in a rural state. Responses from 259 providers and 1,177 nurses revealed that the majority of respondents infrequently used any type of topical analgesic before venipuncture or IV insertion in children, or oral sucrose for infant procedures. Tests for group differences show that providers from urban EDs more frequently used a topical analgesic for suturing lacerations, provided analgesics for blood draws, and gave pain medication to children with abdominal pain. Nurses from urban hospitals used significantly more EBPPM practices than nurses from Critical Access and rural hospitals (P < .001). PERSPECTIVE: In hospitals of all types, ED providers and nurses fail to take advantage of EBPPM practices. This study reveals that health professionals in rural settings are particularly in need of improving the use of recommended pediatric pain management practices.